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OK, lovely. So, um, my name's Sharon. I work locally here in Liverpool. I'm based at Aintree Hospital. Um, and although I did have an elective practice at the beginning of my consultant career, I now just specialize in trauma surgery. But I have also for my sins, uh, got a managerial job within my organization as a divisional medical director. Thank you very much, Steve, for inviting me to to talk. Um, so some of this is going to be a bit philosophical. It's an absolute delight to be in front of the future of orthopedic surgery and future colleagues that will be working with, um and some of this is going to be quite interactive. So please don't just leave me hanging, because that would be, like, really embarrassing. Um, so does anybody Has anybody seen this painting? This isn't a painting. Obviously, this is a print. It's on a slide of painting. But does anybody does? Anybody has anybody seen this painting before? And you know what it's called. So it's called surprised. And it's a painting in the National Gallery, uh, painted by Henri Rousseau. So if you just take a couple of moments just to look at the picture, and then I'm going to ask for a volunteer to say to tell me why. Why do you think that this is called surprised? What's the What's the surprise? Anybody tigers get a surprise. Well, who's who's speaking? I can hear, but oh, there you are. Okay. Okay, so So you think there's a There's something unsuspecting. It's about to pounce. Okay, so that could be it. Did anybody see anything different? Yeah. Okay. Bring it up a grass. Okay, Mr Fisher, that's never going to happen. You know that. You know that. Anything else? Come on. Come on. Think deep lateral thinking. Use are all dead bright, and I know that. So come on. What else can you see? What else might be surprising? Lightning. So what is the surprise that there's going to be a big boom of thunder any minute? That's you see, little little bits of lightning in the background there. And what else might be surprised? Because what do you think? What do you think? Does this work? What do you think this plant here might be? So it's an ornamental house plant because Henry Russo has never actually been to the jungle. And so it doesn't actually know what plants are actually going to be in the jungle because he studied in, you know, a glass house in Paris and saw, like, lots of nice plants there. So So the thing about this exercise was something that I learned when I did a leadership course with the King's Fund a few years ago, and we spent an absolutely fascinating day in the National Gallery and you would be there with other people who you know of a similar, um, interest, you know, aspiring potential medical directors and whatnot. And they plant you in front of a picture and let you look at it for 15 20 minutes. And then everybody sort of then talks about what is it that you see? And it's absolutely fascinating that people see things very differently. We've all got a different learned experience, and actually, it is really easy to make assumptions. And as an orthopedic surgeon, you are a leader within the N. H. S. And it's really important that we work together and with other people, but also make sure that we try and understand that not everybody sees things the way that we see it. And if you can remember anything as you go through your careers, try and remember this picture. And just try and maintain some curiosity because I think it's really easy to lose that when you get sucked into the rabbit hole of not having for trauma lists and how we appropriately manage our patient's. Um but But this is just something so so keep keep that in mind. I feel like I've gone slightly off pieced, but I will bring it back to what I was going to talk about. Um, so these are an AP and lateral radio for at least it's the lateral radiograph of the ankle. Not so much of the knee, but this is a fracture. Dislocation of an ankle. Has anybody in the room managed a fracture like this in the last month? Okay, so yourself at the back of that, Can you Can you remember what the timeline for that patient was? Can you describe what happened? Who reduced it? Sorry that your colleague next to you? Yeah. By whom? Okay. Was that for you and presentations Young in this case, uh, she was sent home. Uh, Boston. Uh, uh huh. Okay, Um, were swelling a problem at three or four days. So it wasn't. That's the answer. Awesome. Good. Okay, so does anybody else a similar experience? Different experience or is that like, Is that kind of it? Yeah. Two weeks. Okay, So tell me that. Why is that to access? They're sitting on board species of that. Okay. Awesome patient experience. Yeah. If it's possible disability used by it would be best. It's not music with if they're swollen. See it? Yeah, and we'd either do it. James. How is Oh, yeah, the weight. People. 56 days do that humblest. They'll be quiet people on this one swing an X ray is going to be out. Unfortunately, expects, Uh, if there wasn't agreed. You think? Okay, so do you know are there any national guidelines for how we manage that injury? Do you know when? When when should it be? Does anybody know? When? When should we manage an unstable ankle fracture? What? What guidance is out there? That's perhaps why we're not doing it. If nobody knows, Have we got we got a national? Yes. Yes. Yeah. So I think I think the I think the boast ones say that they should be on the day of or day after injury, so within sort of 36 hours. Okay. Is that is that achievable for everybody in the room? I think that's obviously not from from what we've heard five days. Yes. Okay. Okay. I thought that might be the the story. Okay, so what about this? So this is a 34 year old, uh, right hand dominant lawyer. Okay, Who's who's come off at speed off one of those electric bicycles Because he likes to have a bit of a rest going uphill. So he's got a high energy but closed intra-articular distal radial fracture. Has anybody seen anything like this? I'll say in the last two months. Yeah. So your hand came up dead quick. So sorry, actually, yeah. I don't got squint that yet. So when what? What was the story for this patient? Oh, thank you. So we have a separate hand department in our unit. So for complex intra articular fractures, we refer to them. And if they accept the referral, they usually fixed within a week for patient's that are not as difficult fracture pattern if they're managed by General trauma team. They usually come to fracture clinic in a week's time and done between eight days to 15 days time. Okay, So are there any national guidelines for the management of inter articular distal radial fractures? I think there's a leading question. Yes. Yes. Okay, so So when When should this be? When should this be managed? According to said, national guideline that we all think we've got one 2 to 3 days time. Yes. Yes, it's three days. It's three days or less than 72 hours. So how many people in this room have the experience of these young people with intra-articular distal radial fractures that are managed within 72 hours? Yeah. Okay. Spaces okay. And and does does reducing them, putting them in the cast tend to reduce the intraarticular bit. Yeah. Not really. No architecture. Okay, so who's who's managed? A patient with something similar to this within the last I'm gonna say week, given what we've heard already about hip fractures. Okay. So, uh, yourself there, I think you put your hand up. You've managed something like this. So what's your experience in how quickly these patient's get to theater? Um so management of these patient's is generally on the next day. Trauma list, if possible within. Well, the guidelines. The laid out for neck femur fractures, Um, so they'll get Ortho geriatric input. They'll get operated on within 36 hours, fit into all of the criteria required for essentially the funding that the hospitals receive for neck of femur fractures. Okay, So if this patient had had fractured the other end of that same bone, would they have got all of that at the moment? Yes, because they think believe it's new. The new guidance. So manage the same. So does everybody is everybody say, seeing that now that the whole femur is the same, like gives the same problem regardless of which bit of it you've broken. Who Who says Yeah, the femur de facto is like one bone. Yeah, and it causes the same problem if it's broken in that patient, whether it's like here or here. So yes, all treated the same. No, it's not that. No. Yeah, it's still not quite there. What about if you were really unfortunate and broke the top end of like the tibia, for example, in that same patient, do they get the Ortho Jerry's within 36 hours? No. Does that stop that patient from walking? Have they got the same medication issues and full risk and do do do Dar's. Okay, So So nationally, we capture We actually capture this data, don't we? We've all we all know about the national hip fracture day space, don't we? We know about the boast and the BP t best practice tariff. Although most people are on block contracts now, so you don't actually get paid it. But anyway, um, so we know about that and that they should be done within 36 hours. I looked at the n h F D last night. Need to get out more. I know, but I was trying to be prepared. So for October 22. 20? Yeah, we're in 2022. So October 2022. So that's last month. What was the national performance of timeliness of surgery within 36 hours? So this is how many? I feel like I need to play your cards right. So go on, give us a starter. 70 higher or lower than 70. How much lower? 65. You were on the same website last night where you need you need you need to go for a beer tonight. I'm going to tell you that now. So 54.7% it was October. Okay, So even when we know we've got guidance and theoretically were being paid for the compliance with that thing and we're canceling young patient's with distal radial fractures, which potentially is going to impinge their function because there's no space on the trauma lists because we're doing all of these hip fractures that were not doing in time. And we're not doing the ankle fractures into until two weeks for the theoretical swelling. That isn't really a thing. It makes me quite curious. Okay, so keep that curiosity. I don't know if you're curious yet or just bored. I don't know. But anyway, somebody be curious and And let's just have a little think about what are the benefits of timely surgery? What? Why is it good to operate on patients who have had fractures early, assuming that they require, you know, obviously they've been adequately consented. And you, uh and they need an operation and you've considered the non operative doodles. If you are going to operate on somebody. Why is it good to do it in a timely fashion? Reduce morbidity and mortality. So what sort of morbidity? No damage. Okay. Anything else? That's what. What? What? OK, yeah. Reduced length of stay pre and post injury. If you have to admit them. Yeah, Yeah. Hm. Why would it cost the hospital less, please? So how does so? Okay, so this is my This is my leadership management thing now. So how does reducing bed days saved the hospital money the most? Yes. Okay, so it only makes a difference, like John was referring to before with theaters, the finance people. So if you can If you are in an organization which is genuinely interested in quality, then yes, that is the thing. If you're talking to a finance director, it will only make a difference about your length of stay malarkey. If you can close beds and decommission them because that's then how you actually save money. Because otherwise, you just don't have an orthopedic patient in your bed. But I can tell you what you will have in your bed because you won't have closed it. But it is. That is what we try. and talk about. But But actually, finance directors get a little bit more into you about that. Anything else? Yeah. Okay. Yeah. So, impact on other patient's. Yeah, Awesome. Who here has ever heard about, like, theater efficiency programs? Have you had, like, external, like Duda's coming in? Consultants going? You need to start your lists on time. Fucking shit, Sherlock. And you need to be You need to be better at your scheduling of theater lists. No shit shell. Well, we need to have, you know, better turnover between cases. You need enough kit. Yeah, Yeah, I know all of that. So, as a surgeon, the only thing that I know that will make me more efficient and be able to do more is give me a fresh fracture. Yeah, it is way, way easier to undertake the surgery you haven't got, you know, that kind of rigidity. And the if that's the right word. In the soft tissues, you can key in fractures far more easily. You know, some of my we've had some s eyes in our place from, you know, proximal humeral. What Not whether you know things that have got names and what Not that get damaged. And you know, all of that is much more difficult if you're not managing acute fractures. So when you're part of an argument, you could say, when these people come in from the consultancy agencies and say, What can you do? Go Well, give me a fresh fracture and I'll get more done for you. And I think that that is a genuine thing. So there's lots of benefits to doing this in a timely way. Okay, So then we've had a really interesting period over the last couple of years, haven't we? When you suddenly have, you know, like, uh, International Pandemic and Covid 19 is suddenly something that we know about that you know, who knew sort of thing and certainly within our hospital, virtually overnight elected the elective program just got switched off, and there were lots of changes to what we were doing in theaters and decisions for operative interventions. Because of, you know, you're a G p aerosol generating procedures. Who thought I would ever be saying that? I don't know. But that became a thing. And so all of a sudden we went down to kind of one trauma list for a period, and you had to kind of go in through one theater. And then there was like, you washed your hands over here and then somebody else put all of your big suit on, and then you sort of walked through. You know, you managed to do, like, one hip fracture in a day because that was all you're allowed to do. They have to be recovered. They're in a bubble and then might make it to the ward. So our ability to be surgeons virtually overnight just disappeared. Got really good at turning patient's. You know, my manual handling CPD totally on it. Awesome. Me and Mr Fischer over, you know, full PPE very, very different experience. So So the federation of surgical specialties. Um, then we're asked to come up with some stuff about clinical prioritization to sort of guide surgical community on how we did use are very, very limited resource, um, to the to the best. Um, and this was really around, you know, the that increasing workload of elective surgery and things that just were not being done. Um, we also did get some guidance about treating things non operatively, so making decisions to just treat things in, you know, plaster casts or what? Not because they just weren't having the ability to get into theater. And so the very first draft of this was about August 2020 and they described these P codes. So P one was like now, now things that needed done and those are some of the examples for TNO and then P one was less than 72 hours, and then the next category was P two. So it was less than a month. And I think the rationale for this initially was that it was either, like you had you had something immediately life all in threatening or you were elective. Now I think we would probably acknowledge that. Actually, there's probably some of our patient's that don't really fit into those categories. But they had in here. No word of a lie in This is a national document. It's NHS policy. Okay, that shows that p too. So less than a month would be fractures. I'm slightly curious as to why that's in italics. Whether it was a well, it doesn't fit there, so we'll put it here. But you know anything. Displaced intra-articular osteochondral defects, ankle and foot Electra non Don't know why they picked on that and not otherwise not otherwise specified, you know. So this was a kind of, you know? Well, if you want to do it in a month, then then that's sort of Okay, So we then had some conversations about that, because I I sort of thought that didn't really make a right lot of sense. And so rather than reinventing the wheel, um, I looked at what the existing N c pod categories, which, you know, we should all be familiar with. All of your emergency theaters. Use those for trying to assess the clinical priorities of things that need done on your and see pod list, whatever. And then myself, with colleagues from the B O, a trauma exchange, and other, uh, specialists, we kind of had a look at, um, evidence that's out there. Specialist opinion, etcetera. Just thought could we devise an orthopedic trauma and see pod classification based on our nice guidance and boast and whatever, whatever. So following numerous discussion's, we then came up with this matrix, um which has got all of the same timing categories that N C pod has, um, so you know, there's like the now, now, now in a bit, a bit longer, A bit longer still, but all of our acute fracture, surgery and acute injury work should be done within a week. We felt that that was, you know, a reasonable, acceptable time period. This would never necessarily be 100% because there will always be some patient, specific factors for why you might not be able to do it. But in an ideal world, this, perhaps, is a matrix that we should be working towards and auditing ourselves against. So I then managed to co opt some colleagues from around the country. So we had 17 hospitals, six of which were major trauma centers. So we were trying to get a bit of a mix between, you know, empty CS and trauma units or or, you know, local hospitals. And this was just a snapshot. So on a particular day, how many patient's according to what their injury was had breached on that particular day? Those categories okay, and we found that it was between nought and 89% with an average of 32%. So on that particular day, there was, um two thirds of patient's were done within the time and one third wasn't and this was done last summer. Now that is probably over egging it. So actually, probably less patient's actually do get their surgery within the time because what it didn't do was look at from the moment that patient presented with their displaced ankle. When were they then operated on? It was only done on the they present on a Monday. The audit was done on a Tuesday, so they have not breached yet. But they didn't get their operation until three weeks on Tuesday. So, you know. So I think it's under estimates it, but nonetheless, from this data. We then had our girth visit. So the lovely Bob Handley came to visit for our orthopedic trauma, girth and I. During the visit, I took the opportunity to discuss my concerns within our hospital about our ability to be compliant with national standards, but also that actually it didn't seem that we were in isolations. Um and so he asked me to do within the girth. National report. They do do case studies. Um, so I've done a case study for the national report, but that made him curious enough to speak to other colleagues and with the B o. A trauma committee, they managed to get the b o A to support the Orthopod audit. Has anybody heard of orthopod or being involved in it? So that's something that collected data over eight weeks, just towards the end of the summer. Um, and it's got I can't remember how many. That's lots and lots of hospitals is about 25,000 patient's that that they've collected data on Willard Ley and Alex trumpeter um uh, working through analyzing some of that data, um, at the moment. But that will give us a better picture of nationally. Where are we in terms of operating on our patient's in a timely fashion according to the standards that we actually feel are appropriate and have got some evidence base behind them. So that's been supported by the B, O. A and the O. T. S. And the results of that will be coming through, um, in the not too distant future. But then the question is, So what? Okay, because in the press, all we seem to hear about at the moment, and I was curious about the stabbing of doctors or whatever that story was. But anyway, forget about that. That story that John was telling us, but the headlines at the moment are all about we're in. We're in a crisis. Our front doors A You know, everybody will know they've got patient's in corridors, and we've just got some really bizarre things going on at the moment. The nursing staff are all gonna strike. Junior doctors may strike. I am going to do my pharmacy training again. I was on the wards last time, Junior doctors' strike. So I better know how to prescribe and use our J A C Uh uh, What else is happening? Uh, people waiting for treatment. So, you know, we're climbing a very, very steep mountain here, aren't we? In terms of, we're not doing our elective recovery program. Um, ambulance delays because they can't offload patient's in hospital. And therefore they can't go back out and get the next one who's had a heart attack. Cancer patient's are doomed. Um, and they might reduce our budget as well. So some of these things. So cancer targets emergency access targets the elective recovery program. All of these are actually sort of mandated statutory things that trusts should be doing. And we're not doing that. The things I'm talking about with our orthopedic patient's are actually just our own guidelines. They are national guidelines, but they are. They've been written by people who have an interest who are trying to improve the quality of care by coming up with standards. And orthopedics is, you know, with Chris Moran, um, and Keith Willett before him, you know, trail blazing in terms of having the standards of care, you know, it is exceptional. You don't have that being, you know, somebody who is looking after other surgical departments in my hospital. You know, other other specialties don't have that maturity of setting our own line as to what do we think we should be delivering? The problem is, nobody else is looking at it. We've got the hip fracture data, and it should be be PT. And if you're not on block contract, your finance manager would probably be breathing down your neck going. You need to improve the compliance with this because we're losing tens of thousands of pounds each month, but they're not because we're on block contracts, so they're not interested BPT for major trauma is exactly the same thing. And so it's It's so it is. So what? How how do we make how we manage our patient's make things better for our patient's save some money, stop affecting our elective patient's, use our resources more effectively. So we know there are benefits to our own standards. I think we're pretty robust in what our own standards should be, but we don't actually know how compliant we are. This orthopod audit is going to be a starter for 10. But what do we then do with that? That information, you know, and what is the future for how we want to be delivering our services and how we hold ourselves to account about that delivery of services. So I'm I'm interested in curious people might have thoughts that they want to contribute, But you know, there is a potential tsunami of, you know, older people with frailty who have got more than just femurs. They've got necks and heads and tibias and ankles and God knows what, all of which will be an increasing burden to the orthopedic trauma community. So how how do we use the information that We've got to actually improve how we deliver care to our patient's. Does anybody have any thoughts? Reflections or it's just all soaking in at the moment. Yeah. So services. So the happen again. Yeah. The n t CS are so ambulations go down the list of priorities because that means I would like, you know, limited bet. Yeah. Yeah. Is there an argument? Uh, for a destruction of services back out, We spoke of the MTC to say Well, actually be suspected. Directed a way to try and be violence that would help. So who who here has has be? Just be honest, you're amongst friends were all you know, it's all grooving. Who here has aspirations of being? I'll call it. Okay. Hip arthroplasty surgeon in a trauma unit. In fact, no. Let's go. Let's go to two joints. Who wants to be? Who wants to be a lower limb? Arthroplasty surgeon in a trauma unit. Okay, bless you. I'm sure you're not alone. I'm sure you're not. And so this concept that we're now going to say, you know, I work in a major trauma center. You want me to do all of all of this and what I can't do therefore is this. There you go. And, you know, already over here that there's a problem that elective services are going to be impacted by by that potential move. Does that sound awesome? Sorry. Slight change by the party. Uh, represent a huge Uh huh. And we'll address the fact that yeah, uh, uh huh uh, resident. So do went to block that. It's really interesting. Well, all done, uh, from your this, uh, this much good morning. Yeah. So I think I think peri prosthetic fractures. There's a session, like, whole session on that, which, which I think I think is, uh is, you know, going to be a fascinating um, But I think one of the things that you know, we did get a positive tick for with our orthopedic girth visit is that because of the size of our department that we've got now, we have, uh, people who have a predominant elective, hip or knee arthroplasty interest, actually working at the M. T. C. So those people are available to help. So if we've got a fracture that needs a big, bigger bit of metal putting in joint replacement anything, then they can help do that sort of thing. But But, as you say, peri prosthetic fractures. These are happening in your hip fracture type population, aren't they? And you know, you you can't probably just be managing those in one center, so you do need to have that expertise across the patch. So, you know, I've I've got my views. I will be doing what I can to kind of influence and change locally, regionally, whatever over a period of time. But you know this. This will become what your priority is. I think that regional networks collaboration use of resources across a patch is absolutely, absolutely paramount, I suppose, for trauma, you know, managing to establish perhaps a regional M d T. But because of the nature of its trauma, these would need to be potential on a daily basis. But it's not now that we're used to using teams and so forth. It's not without the wit of man to imagine how you could, you know, organize these things to discuss cases, and then you know that you've got some governance arrangements about what's going on. Where I think the whole thing about frailty, you know, this is a bit about. How do we work with our, you know, primary care providers. How do we how do we work with population health? You know, about influencing what our Children are doing now to reduce their risk of frailty and, you know, fragility fractures later in life. How do we get to a point where where we've got effective use of resources. So, uh, and then the pathway. So we we've got a virtual fracture clinic that we inherited as an organization when the Royal and Entry merged in, uh in Liverpool and the virtual Fracture clinic is great because, you know, you can reduce the face to face appointments by about 30%. So that's that's brilliant, really effective use of resource. But there are some unintended consequences. I think to that so that displaced ankle fracture in my hospital would be most likely reduced by the A N D team. They would be re enabled on a pair of crutches by one of the physios and sent home referred to VFC where they'd be discussed, and they would then come to the next foot and ankle clinic because only foot and ankle surgeons can manage ankle fractures. I'm told. Yeah, um, so they would then come to a foot and ankle clinic, and then they would be looking for a foot and ankle trauma list. And so we have this 2 to 3 week delay for fixing a by mail Eola ankle fracture. You know, when I was a trainee, those patients' would have been referred to me. I'd have done the manipulation that have been brought into hospital that have been operated on the next day. And, you know, that was how it was. Have the resources changed? Has the demand on our services changed? Is there something different that we're doing now? Maybe it is. Have we looked at in individual hospital hospitals? What the capacity and demand is because if there is a genuine increase in demand, then we need to be matching that with capacity. So I think there are a number of different options I think we'll be. I'm curious to see what the results, if you like or what the orthopod audit tells us. But when we you know, are reporting that back to NHS England, we also need to have a bit of the So what? And what is the plan? I think it's important that if we do set ourselves, you know, specialty standards, then it's because we think it's kind of important and the benefit to that. But then we need to know whether we're compliant with it or not, because we only actually know for hip fractures and open fractures. And we're we don't pit our standards for either of those. So what's going to be the lever? Is it money? Is it about the way that we you know, uh, incentivize the compliance with things? It's the money made a difference for hip fractures? Is that what's going to make a difference for people to be compliance with our standards? Or is it going to be something else? So I'm going to leave it there. I'll take any questions if you have any, um, anybody who wants to contact me more than more than happy to do. So, um, the event organizers may well be able to pass on my email or I'm at Liverpool anyway, So I'm happy to. I'll be here for a bit this afternoon, and I'm here again tomorrow. So if anybody has any ideas, thoughts, things that you think, Do you know what this is? Maybe what we should be doing. Then let me know. Thank you.